It's safe to say that most people have been to the doctor's office and had their physician order up a lab test of some kind for them. Lab tests are an essential piece to good health. Lab tests help physicians screen for, diagnose and treat a wide variety of medical conditions, and on a larger scale, they help physicians improve the level of care they're able to give, as well as enhance and lengthen the lives of patients.
So when the dust settled after the American Board of Internal Medicine Foundation (ABIM Foundation) made public its "Choosing Wisely" campaign -- a sweeping new healthcare initiative that focuses attention on frequently used medical tests and procedures -- questions emerged as to how the initiative may affect clinical labs across the nation.
There are a number of diagnostic tests that the Choosing Wisely list addresses. However, only the recommendation by the American Academy of Family Physicians (AAFP) -- that Pap smears should not be performed on women younger than age 21 or women who have had a hysterectomy due to non-cancer diseases -- directly affects labs. "As of right now, that's really the only test I can see that might apply to us," said Alan Mertz, president of the American Clinical Laboratory Association (ACLA) in Washington, D.C.
That said, the initiative portends well for, and coincides with, increased efforts by some lab-specific professional organizations to take a more active role in working with physicians to ensure proper utilization of diagnostic tests. "Many labs actually already do work in concert with their physicians to determine proper utilization," said Catherine Otto, past president of the American Society for Clinical Laboratory Science (ASCLS). "Ordering tests wisely is something we think is very important, and this initiative fits with what we believe about using evidence-based medicine to choose proper tests that help patients -- we're all for that."
One of the goals of the initiative is to help educate physicians and patients alike as to what questions to ask about certain tests so as to ensure proper care, and to make sure that patients aren't subjected to unneeded invasive tests and procedures that don't improve health. But cutting costs associated with unnecessary testing is a secondary target of the initiative. According to a 2009 Thomson Reuters report on healthcare in the U.S., an estimated $700 billion is wasted annually. Cutting some of that waste is possible without affecting quality or access to care, according to the report, and that includes diagnostic testing. And while cutting back on unneeded tests can help, lab testing only accounts for about $65 billion, or 2.3%, of the total healthcare budget in the U.S. Yet lab tests inform approximately 70% of doctor decisions.
Reducing costs has, on its own, provided a catalyst for helping physicians and laboratorians connect. "Because of health insurance restrictions, labs are often forced to follow up with doctors," said Mertz. "More recently, labs have worked harder to follow up with physicians who ordered tests to make sure they are appropriate, and to make sure they're covered," he added. "The lab has an ethical and often legal obligation to run the tests and get the results to physicians. The labs also want to be paid for performing that service," he continued, and oftentimes that means ensuring that the tests are medically necessary.
Organizations like the ASCLS, and even some managed care consortiums like Kaiser Permanente, are working toward developing protocols that create a dialogue between physicians and laboratorians, and the inclusion of the American Society for Clinical Pathology as a working partner on the Choosing Wisely campaign could encourage other like organizations to join as well. Added Otto, "I would consider asking the board of ASCLS to become involved with the Choosing Wisely initiative because we think it's great to help educate people -- and physicians -- about what's appropriate and what isn't in terms of testing. And in particular, giving information directly to patients is especially outstanding if it can be made understandable for them." Otto also pointed out that organizations are increasingly looking toward professionals with advanced degrees to staff their labs. "ALCS is a proponent of clinical laboratory science, and the job of lab professionals will be to talk to clinicians and help them pick the proper tests to order. because there are improper tests being ordered. Those professionals are also becoming more and more helpful to clinicians in interpreting tests."
Nine specialty medical societies in all are participating in the initiative, with each of those recommending five diagnostic tests or procedures within their specialty that are routinely ordered for thousands, and sometimes even millions, of patients. These tests and procedures have been identified as possibly warranting re-evaluation by physicians and patients as to whether they will provide useful information or lead to a positive outcome. Examples of common tests that made the list are stress tests, which have been deemed unnecessary for healthy adults with no cardiac symptoms, and chest X-rays prior to outpatient surgery for patients with normal physical exams. You can learn more about the initiative by visiting www.choosingwisely.org.
Chris Kinsey is a freelance writer.